A Perception Gap

A PERCEPTION GAP
Health Management Quarterly, August 1991

by Daniel Yankelovich and John Immerwahr, Ph.D.

The gap between public perception of a problem and expert perceptions must be narrowed before solutions can be found.

This article presents preliminary findings on research by the Public Agenda Foundation, a nonprofit, nonpartisan research organization. When complete, this research will provide one basis for a major public-television special on health policy being produced by WGBH-TV in Boston under a grant from Baxter International Inc. and for accompanying educational materials being produced by Public Agenda for a nationwide program of community and town meetings.

The findings discussed here are based on focus groups conducted in nine cities across the country between January and June 1991. We have also reviewed existing survey data and interviewed a number of experts and decision-makers in the health-care field. While findings from focus groups should be considered preliminary until they can be confirmed through surveys, our observations here reflect the views of a cross-section of Americans from around the country.

Despite growing recognition that America's health-care system is at a crisis point, the country has not been able to rally around any of the solutions being debated. Though part of the problem is that whatever we do will be painful and expensive, our research shows that the current stalemate is caused by something deeper than just an unwillingness to make hard choices.

Our study of public-policy issues over the years suggests that such stalemates are often caused by what we call an "expert/public gap." There are deep divisions between the way experts see a problem and the way the public sees it. When such a gap exists, the country's leaders and the public talk past each other, each side wondering why the other does not listen. The expert/public gap in the area of health care is as great or greater than in any other area we have investigated. Defining that gap and finding ways to bridge it are essential. The experts we interviewed and the participants in our focus groups both identified the growing cost of health care and the need to provide coverage to people who are uninsured as the biggest problems facing the system. Some comments from focus group participants:

"Health care is pretty bad. It is too expensive, and there are so many people who aren't covered. Something needs to be done."

"Health care is running amok. For me, my premiums have gone up every year for the last three years. But the worst problem is for the people who don't have insurance. Low-income families can't keep up with medical bills."

National surveys have found that large majorities of Americans feel the health-care system requires fundamental changes or should be completely rebuilt. The reasons given for this judgment are rising costs and the unavailability of coverage.

This apparent basis for agreement between the experts and the general public falls apart dramatically, however, when people are asked why costs are rising so rapidly. Our focus groups revealed that, for the public, the main forces driving up costs are human– and largely moral–factors such as greed, high salaries, corruption, waste and unnecessary testing. Although people disagreed about which human factors were most at fault, nearly everyone believed that the real cause of the problem was that someone was making too much money. The consensus was that the health-care system has not a cost crisis but a profits crisis. Some typical comments:

"I think the doctors are in cahoots with each other. You see one doctor and they send you to another one."

"I don't mind them getting rich, but they are taking shortcuts–they are stealing it. For example, AZT costs $800 a month to maintain; it costs pennies to manufacture, [and] the research was done by the government with our tax dollars."

"As long as the American Medical Association has anything to do with health, we won't have health care at all. The poor people are being bled to death."

"The costs are going up because of greed. It's the money. My asthma medicine costs $31 for a month's supply, but right down here in Tijuana it costs $2. Same thing."

In essence, the public defines the health-care crisis as an old problem: An age-old human failing–greed– has taken over. Since it is an old problem, either there is no solution, or the solutions will be familiar ones.

In contrast, experts and political leaders see the problem of skyrocketing costs as essentially a new one, caused by factors the system has not dealt with before. Though agreeing that factors such as malpractice awards and insurance, excessive administrative costs, and cost-shifting may explain why the country's base costs are higher than those of other countries, the experts suggest there are two major reasons why costs are going up so rapidly in this country and in the other industrialized democracies. First, the number of older people in the population is increasing, and older people are the major consumers of health care. (Although older people make up only one eighth of the population now, they already account for more than a third (36 percent) of the nation's health-care costs.) Second, many of the experts point to the explosive cost of new technologies and advances in medical techniques. They argue that saving lives–while highly desirable–does not save money. A patient who might have died quickly in an earlier era can now be saved, at considerable cost, to live a longer life in which he or she will, sooner or later, need further medical treatment.

When we presented these concepts to members of the public in our focus groups, it was immediately clear that these ideas were new–sometimes even shocking–to our participants. Most had never considered the idea that there is a price tag associated with the graying of America, or that in health care (in contrast to other areas) technology could raise costs rather than reduce them. Their comments reflect considerable confusion about what actually contributes to the cost of care as well as discomfort with laying blame for the problem on what seemed to them a vulnerable segment of the population. Some representative reactions:

"Their bills get covered by Medicare anyway. That isn't a big factor."

"We are all aging. How many older people are in the doctor's office every day? I think it is the people who are in the hospital every other day who run it up, and they can be any age."

"The costs go up more because of malpractice than because of the number of older people."

Although most respondents readily agreed that abuses of technology are a major factor in the explosion of health-care costs, they were totally unconvinced by the argument that the technologies themselves generate increases in costs. For example, some respondents commented:

"It is not the new technologies, but the duplication."

"The new technologies themselves are not necessarily a cost factor, but when every hospital in the area has to have one, that inflates the health-care costs."

Even when the moderator used specific examples (coronary-bypass operations and neonatal units) to explain why this might be so, respondents seemed to reject or be confused by the idea.

Most supported new technological developments. They frequently regarded technological sophistication as the most positive aspect of American health care and saw technology as part of the solution rather than part of the problem. That's consistent with a 1989 Gallup survey, for example, which found that only 20 percent of the public believe that doctors use too much technology in treating and diagnosing patients. The vast majority (72 percent) believe that doctors use either the right amount (59 percent) or not enough (13 percent).

Thus, the gulf between the public's human and moral definition of the problem and the experts' technical and structural definition is tremendous. Given such basic disagreement, it is hardly surprising that there is little public support for any of the steps that might address the problem.

For example, many experts believe that the United States will have to allocate or set priorities for the most expensive procedures. Most of our focus-group participants were totally opposed to–indeed repelled by–the idea of rationing any procedure, regardless of its cost. A 1987 Harris survey also found that 71 percent of Americans believe that "health insurance should pay for any treatment which will save lives even if it costs one million dollars to save a life."

This is in direct contrast to the attitudes of leadership groups. Only 23 percent of political leaders, for example, agree with that statement.

Only on the surface is there agreement about how to deal with the problem of coverage. Many surveys show that support for Canadian-style universal coverage is between 60 and 70 percent, depending on the question asked, but this consensus is paper thin. Support drops off sharply when people are confronted with the costs of this proposal, or with the possibility that they might have less choice, or have to wait longer or travel farther for treatment.

Our research suggests that the reason people reject proposals that have costs or reductions in care associated with them is that they believe either that sacrifice is not necessary or that it will be fruitless because any savings will be absorbed by the greed in the system. According to a 1990 Los Angeles Times poll, the majority of Americans (69 percent) believe that "medical costs in the United States can be reduced substantially without affecting the quality of health care."

Americans place a high premium on health care, which they regard as a fundamental right. There is almost universal agreement (91 percent) with the idea that "everybody should have the right to get the best possible health care–as good as the treatment a millionaire gets." Public Agenda's study suggests that people are not willing to give up on that fundamental right just, in their view, to put more money in the pockets of greedy malpractice lawyers, or to indulge insurance companies and hospitals in their propensity to waste money on paperwork.

The gap between the public's and the experts' perceptions must be addressed before the country can begin to solve its health-care problem. While there's no easy way to do that, a few principles may be suggestive.

Recognize the public's concern. On an issue where people have strong feelings, most people bring with them a pet theory or preoccupation–an idée fixe. If their preoccupation is not addressed, they will not listen to anything else one has to say. In health care, the public's idée fixe is that the country can solve its problems by eliminating waste and excess. Until this concern is heard, the public is unlikely to be responsive to other suggestions.
Deal with the waste issue head on. There are hundreds of proposals designed to limit waste (including limiting malpractice claims, preventing doctors from referring patients to labs where the doctor has a financial stake, and establishing more rigorous controls on duplication of technology). A coherent set of waste-reduction proposals should be vigorously and publicly pursued as a first priority.
Hammer away at the connections. An outside observer might reasonably conclude that our health-care system had been deliberately designed to obscure the connections between costs, demographics and technology. The costs of high-tech medicine are all paid by insurance, and many jobholders don't even directly pay their own insurance bills. The architects of Medicare deliberately designed the program to make it appear to be an actuarially sound insurance system, further obscuring the cost of medical care for older people. Again there are many proposals already available, ranging from higher copayments to a payroll tax dedicated to financing a national health system. Such proposals should be debated not only on technical grounds but also in terms of their educational value.
Don't expect quick solutions. Public attitudes toward health care have taken a long time to evolve. In many ways, the public's views accurately reflect what leadership has explicitly or implicitly told them in past decades. Change in deeply set values will come only gradually.

In fact, there already are signs of a shift in the public's basic values. The research firm DYG, Inc. has found a significant shift in the public's willingness to forgo heroic measures designed to preserve life under any and all circumstances. DYG's annual SCAN project, which identifies and tracks social change, shows that over the past four years, there has been a decline in the belief that human life is so sacred that anything and everything should be done to keep an individual alive for as long as possible.

Most of the reforms now being debated by leadership cannot possibly succeed without a substantial level of public understanding and support. Until the public's mindset and preoccupations are taken seriously–and responded to–reform will come slowly, if at all.